SOM ClIK Pilot Program Application Principal Investigator (Last, First, Middle):

February 23, 2015

The University of Texas Health Science Center at San Antonio

School of Medicine Clinical Investigator Kickstart (ClIK) Program

Cover Sheet and Checklist

Project Title: ______

Contact Investigator: ______

Academic Department(s): ______

Telephone: ______Email: ______

Project Start Date: ______Amount Requested: ______

Please List All Other Investigators

Name Title Department/Institution Email

______

______

______

______

Assemble the application in the following order

□ This cover sheet and checklist

□ Project Summary/Abstract (NIH form page)

□ Budget (NIH format)

□ Budget justification-no faculty salaries (NIH format and form page)

□ Specific Aims (1 page maximum)

□ Overall project narrative (4 page maximum)

□ Literature citations (1 page maximum)

□ Target funding mechanism and description of plans for external funding (1/2 page maximum)

□ NIH Biosketch for all investigators (NIH format new or old format, limit 4 pages/investigator)

□ Program announcement (if applicable)

□ Summary Statement(s) (if applicable)

Applications must be submitted by email to the Research Dean’s Office () by April 6, 2015 at 11:59p.m.


PROJECT SUMMARY/ABSTRACT (use 11 pt font and fit within text box 7.5” wide X 6” high)

KEY PERSONNEL

Name eRA Commons Organization Role on Project

Principal Investigator

Co-PI

Co-PI

DETAILED BUDGET FOR INITIAL BUDGET PERIOD

DIRECT COSTS ONLY

/ FROM / THROUGH
PERSONNEL (Applicant organization only) / Months Devoted to Project / DOLLAR AMOUNT REQUESTED (omit cents)
NAME / ROLE ON
PROJECT / Cal.
Mnths / Acad.
Mnths / Summer
Mnths / INST.BASE
SALARY / SALARY
REQUESTED / FRINGE
BENEFITS / TOTAL
PI
Co-PI
Note: Do not show
faculty base salaries
SUBTOTALS
CONSULTANT COSTS
EQUIPMENT (Itemize)
SUPPLIES (Itemize by category)
TRAVEL
PATIENT CARE COSTS / INPATIENT
OUTPATIENT
ALTERATIONS AND RENOVATIONS (Itemize by category)
Not allowed / 0
OTHER EXPENSES (Itemize by category)
CONSORTIUM/CONTRACTUAL COSTS / DIRECT COSTS / 0
SUBTOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD / $
CONSORTIUM/CONTRACTUAL COSTS / FACILITIES AND ADMINISTRATIVE COSTS / 0
TOTAL DIRECT COSTS FOR INITIAL BUDGET PERIOD / $


BUDGET JUSTIFICATIONS

PERSONNEL

CONSULTANT COSTS

EQUIPMENT

SUPPLIES

TRAVEL

PATIENT CARE COSTS

OTHER EXPENSES

SPECIFIC AIMS (1 page maximum)

OVERALL PROJECT NARRATIVE (4 page maximum)

LITERATURE CITATIONS (1 page maximum)


TARGET FUNDING MECHANISM AND DETAILED DESCRIPTION OF PLANS FOR OBTAINING EXTERNAL FUNDING (1/2 page maximum)

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